A Focus on Women's Health
••Winter 2005/Vol. 9, No. 1

Clinical Contributions

Preventing Unintended Pregnancy: Eight Years of Effort at KP San Diego | to pdf >>
By Charles I Jones, MD; Wansu Chen, MS; Karen S Mulligan, RNC, CPHQ

Introduction

Of our Kaiser Permanente (KP) San Diego members, 1391 had pregnancy termination in 2003. In addition, about 1700 (32%) of births to mothers who were KP members in San Diego in 2003 were the results of mistimed or unwanted pregnancies. Couples have difficulty consistently using effective contraception, and a busy health maintenance organization is challenged by the need to consistently provide excellent contraceptive education, counseling, and services to a very large at-risk population. Highly effective contraceptive methods are available, and providers of contraceptive care, together with their patients, have the tools available to dramatically reduce unintended pregnancy.

Formation and Activities of a Multidisciplinary Task Force

In the past eight years, KP in the San Diego area has focused on this problem in adults and teens through use of a task force (sponsored by the Quality Resource Management Department) for prevention of unintended pregnancy. Membership in the task force includes a physician, midlevel practitioner, and nurse supervisor from each of three departments: primary care, pediatrics, and obstetrics/gynecology. The Member Health Education, Social Service, Pharmacy, Quality Resource Management, and Health Appraisal departments also are represented. Since 1996, the group has met quarterly with two goals: to identify areas for improvement and to implement changes designed to improve contraceptive services.

The frequency of unintended pregnancy has been monitored by evaluating abortion rates. More recently--since 1999--unintended births also have been monitored through responses to the prenatal questionnaire. Since 1996, a goal of the task force has been to decrease the abortion rate by 5% per year. In 1999, the task force goal added the goal of decreasing unintended births by 5% per year.

In the past eight years, the task force has identified many areas for improvement. These problem areas have been addressed either through education or by improving contraceptive services. A few important examples are described here.

Contraceptive education has been a major focus: The task force has used medical office chart reviews to identify and highlight opportunities for improving contraceptive care and to educate providers and staff. The first chart review (in 1996) evaluated inreach opportunities. The medical office charts of women who had had an abortion were reviewed. Ninety-three percent of these women had a medical office visit in the obstetrics/gynecology, primary care, or pediatrics department in the year preceding the abortion. However, contraception was noted in less than 50% of these visits.

These findings were shared with all involved provider groups. Another observation was that abortion was likely to be repetitive. A third of the patients were having their first abortion as KP members. A third were having their second abortion, and a third were having their third through eighth pregnancy termination. With this information--that two thirds of abortions were done in women who had already had an abortion--a new standard was established: All patients who receive a referral for an outside contracted abortion also receive a follow-up appointment for contraceptive counseling with a midlevel practitioner in the obstetrics/gynecology department. A substantial decline in repeat abortion has been noted since this program was instituted.

The Emergency Contraception Demonstration Project

An emergency contraception demonstration project was undertaken in the San Diego area in 1997.¹ This project was a joint undertaking of the KP Southern California Region and the Pacific Institute, a not-for-profit organization whose mission is to advance women's health. The project was funded by a consortium of external foundations. Project participants at KP included Diana Petitti, MD, MPH; David Preskill, MD; Debbie Postlethwaite, RNP, MPH; and Howard Switzkey. Project participants at the Pacific Health Institute were Marie Harvey, MD; and Linda Beckman, MD. The project paid for Ms Postlethwaite to work full-time in San Diego on developing a structured program of education and training for personnel in the primary care and obstetrics/gynecology departments. The project established protocols to make emergency contraception readily available to our Health Plan members. The broadening of contraceptive services has resulted in fewer unintended pregnancies. Information on abortion rates at KP San Diego and in the rest of the KP Southern California Region that are included in this article were first calculated as part of the project.

Women at risk for unintended pregnancy frequently present asking for a pregnancy test. When appropriate, contraceptive counseling at the time of pregnancy testing has great value. The San Diego program has followed the lead of Richard Boise, MD, and Ximena Borquez, MD, from KP Antioch, who have popularized this counseling in the KP Northern California Region.²

Recent Improvement of Member Contraceptive Benefit

The Kaiser Foundation Health Plan in California recently improved the contraceptive benefit to KP members by making available injectable and implantable contraception, IUDs, and emergency contraceptives for all members without including a pharmacy copay. This benefit change took effect in January 2002 and was expected to substantially reduce the number of unintended pregnancies by ensuring that several highly effective contraceptive methods became more readily available. This contraceptive benefit is probably a major contributor to the rapid decline in the rate of abortions reported throughout the entire KP Southern California Region in 2002 and 2003.

In response to this Health Plan benefit change, a current focus of the San Diego task force is to evaluate our experience with IUDs and to promote their appropriate use. The IUD is a highly effective, reversible contraceptive method which is underused in the United States. Increasing appropriate use of IUDs would substantially decrease the number of unintended pregnancies.

Conclusion

These projects are a few of the many important activities the task force has been involved in during the past eight years. Contraceptive services have improved, and rates of unintended pregnancy have decreased. The initial goal (set in 1996) was to decrease the rate of abortion by 5% per year, and averaged results for the past eight years show that this goal has been met (Tables 1,2). A decrease in the rate of unintended births recorded at KP San Diego--from 40% (in 1999) to 30% (in 2004)--has also been observed. Thus, the second goal, added in 1999, to decrease the rate of unintended births by 5% per year--also has been met. For comparison, the abortion rate nationally for women aged 15 to 44 years decreased from 21 abortions per 1000 women (in 1996)³ to 16 per 1000 women (in 2001, the most recent year for which data are available).³

Unintended pregnancy affects many of our members and their families. Persistent, focused attention to this problem has been associated with a large decrease in the number of unintended births and abortions.

Acknowledgments

The Quality Resource Management Department strongly encouraged development of this program.

Diana Petitti, MD, and Debbie Postlethwaite, RNP, critically reviewed the manuscript.

References

1. Petitti DB, Harvey SM, Preskill D, et al. Emergency contraception: preliminary report of a demonstration and evaluation project. J Am Med Womens Assoc 1998;53(5 Suppl 2):251-4.
2. Boise R, Petersen R, Curtis KM, et al. Reproductive health counseling at pregnancy testing: a pilot study. Contraception 2003 Nov;68(5):377-83.
3. Strauss LT, Herndon J, Chang J, et al. Abortion surveillance--United States, 2001. MMWR Surveill Summ 2004 Nov 26;53(9):1-32.
   
   
   
   

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